Clinical Quality and Regulatory Specialist

This is a fully remote position, open to applicants in Georgia.

📋 Description

• Assist in ensuring compliance across Health Services functions such as Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy.

• Track and report on operational activities and functions delegated within Health Services.

• Work in partnership with Health Services leadership and Compliance on regulatory and delegated responsibilities.

• Create and implement internal audit processes.

• Conduct routine and ad hoc compliance monitoring activities.

• Oversee delegation of responsibilities to vendors and subcontractors.

• Review utilization management decision-making staff on a monthly basis to ensure adherence to clinical policies and processing timeframes.

• Act as a liaison between Health Services, Compliance, and Fraud, Waste, and Abuse teams concerning FWA cases.

• Evaluate, interpret, and report on the implications of new and updated regulations and requirements.

• Address compliance queries from both internal and external auditors.

• Prepare, present, and submit necessary reports to agencies and organizational committees.

• Represent Health Services during meetings, committees, and audits.

• Apply LEAN methodologies and principles of quality improvement.

• Track KPIs using visual management tools and daily huddles, identifying areas for improvement.

• Review and update policies, procedures, training materials, communications for members and providers, and handbooks to ensure compliance.

• Assist in the education and onboarding programs for employees, vendors, and subcontractors.

• Serve as a backup for other Health Services personnel and engage in committees and task groups.

• Adhere to privacy policies and HIPAA regulations.

• Carry out additional duties as assigned.

⛳️ Requirements

• At least six years of nursing or clinical behavioral health experience with diverse healthcare exposure.

• A minimum of two years of experience in the insurance industry.

• Must be a Registered Nurse, Licensed Clinical Psychologist, Licensed Clinical Social Worker, or similar behavioral health professional with significant experience and/or credentials.

• Possess current unrestricted state license(s).

• Maintain an up-to-date clinical knowledge base and certification.

• Extensive knowledge of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT codes.

• Familiarity with health insurance and state-mandated benefits.

• Understanding of contractual benefits.

• Capability to utilize computerized systems for data entry and retrieval.

• Knowledge of patient confidentiality, privacy, and health records security.

• Proficient in strategy deployment, daily operations, visual management, operational improvement, and auditing practices.

• Ability to work independently with minimal supervision as well as collaboratively within a team.

• Competence in reading and comprehending written and spoken English.

• Strong communication skills for clear and effective interaction.

• Willingness to travel approximately 10% of the time.

🏝️ Benefits

• Equal opportunity employment.

• Chance to contribute to social justice, equity, diversity, and inclusion initiatives.

• Access to employee education and continuing education programs.

• Opportunity to obtain Certified Case Manager (CCM) certification within two years, or 60 CEUs in Utilization Management areas of focus.

• Ergonomically designed equipment provided.

• At-will employment.